Glenoid implant for minimally invasive shoulder replacement surgery

ABSTRACT

A glenoid implant is disclosed which has a protruding surface on a first side arranged to engage the surface of a cavity formed in a glenoid extending between peripheral glenoid surfaces and a flat surface adjacent the protruding surface of the implant arranged to engage the peripheral glenoid surfaces adjacent the cavity. The implant also has a wear-resistant surface on a second side opposite the flat surface and the protruding surface.

CLAIM FOR PRIORITY

This application is a division of application Ser. No. 10/917,266, filedAug. 11, 2004. As set forth in that parent application, applicantclaims, under 35 U.S.C. § 119(e), the benefit of priority of: 1) thefiling date of Aug. 11, 2003 of U.S. Provisional Application No.60/494,289, 2) the filing date of Oct. 8, 2003 of U.S. ProvisionalApplication No. 60/509,655, 3) the filing date of Oct. 16, 2003 of U.S.Provisional Application No. 60/511,805, 4) the filing date of Nov. 19,2003 of U.S. Provisional Application No. 60/523,401, 5) the filing dateof Jun. 15, 2004 of U.S. Provisional Application No, 60/579,893 and 6)the filing date of Jul. 2, 2004 of U.S. Provisional Application No.60/585,033, the entire contents of each of which, including said parentapplication, are incorporated herein by reference.

BACKGROUND OF THE INVENTION

1. Field of the Invention

The present invention relates to methods, instrumentation, and implantsfor orthopaedic surgery and, more specifically, to rotator cuff sparingprocedures and associated devices for shoulder replacement surgery.

2. Discussion of Related Art

Orthopaedic surgeons perform joint replacement surgery for patients whosuffer pain and physical limitations caused by joint surfaces that havebeen damaged by degenerative, traumatic, or other pathologic processes.The functional outcome from these joint replacement surgeries isdirectly related to the degree of morbidity associated with the surgicalmethod and the ability of the method to best restore the natural anatomyand biomechanics of the joint. Orthopaedic surgeons are continuallysearching for ways to improve outcomes for joint replacement surgery bydeveloping methods of less invasive surgery to limit surgical morbidityand by developing novel methods and implants to better restore thenative joint anatomy.

Conventional shoulder replacement surgery has several limitations. Itrequires an extensive exposure that irreversibly damages the rotatorcuff and still fails to gain sufficient joint access to properly restorethe native anatomic relationships of both the humeral head and glenoidsurfaces. Also, there remain issues with glenoid implant fixation andearly loosening.

Conventional methods utilize a large anterior deltopectoral exposure.The anterior humeral circumflex blood vessels are typically ligated andthe anterior (subscapularis) musculotendinous unit is transected. Theshoulder must then completely dislocated both anteriorly and posteriorlyto prepare the humeral and glenoid joint surfaces. This can causeexcessive traction on the arm which has resulted in injury to the nervesof the brachial plexus (Lynch N M, Cofield R H, Silbert P L, et al.Neurologic complications after total shoulder arthroplasty. J ShoulderElbow Surg 1996;5(1):53-61.).

With regards to shoulder replacement surgery, all conventional methodsrequire surgical transection of a rotator cuff tendon to gain sufficientexposure of the joint surfaces of the shoulder (See U.S. Pat. No.4,550,450, entitled, “Total Shoulder Prosthesis System”, the entirecontents of which are incorporated herein by reference). After the jointsurfaces are replaced, the rotator cuff tendon must be surgicallyrepaired with suture material. This tenuous repair necessitates anobligatory period of approximately six weeks for the rotator cuff tendonto heal before advanced shoulder rehabilitation can be performed. Thissurgical transection and subsequent repair, as well as the delay inrehabilitation, hold significant consequences for the functional outcomeof the shoulder replacement including permanent weakness and decreasedrange of motion (Miller S L et al., “Loss of subscapularis functionafter total shoulder replacement: A seldom recognized problem”, JShoulder Elbow Surg. January-February2003; 12(1):29-34).

Additionally, despite the extensive exposure, conventional methods forshoulder replacement surgery still fail to properly restore the nativeanatomic relationships of the joint surfaces of the shoulder.Conventional methods prepare the humeral surfaces of the shoulder jointby referencing off the intramedullary axis of the humeral shaft. Thisposes great difficulty for the surgeon since the intramedullary axis hasan inconsistent relationship to the humeral surface. The humeral jointsurface also possesses a complex anatomy with significant variabilitywhich cannot be entirely restored with conventional methods andimplants. There exists much variability in the humeral head neck-shaftangle, posterior and medial offset, version (rotation), height,thickness, and radius of curvature. (Boileau P, Walch G, “TheThree-Dimensional Geometry of the Proximal humerus”, J Bone Joint SurgBr 1997; 79B: 857-865; lannotti J P, et al. “The Normal GlenohumeralRelationships. An Anatomic Study of One Hundred and Forty Shoulders”, JBone Joint Surg 1992; 74A(4):491-500; McPherson E J, et al.“Anthropometric Study of Normal Glenohumeral Relationships”, J ShoulderElbow Surg 1997;6:105-112; Soslowsky L J, et al. “Articular geometry ofthe glenohumeral joint”, Clin Orthop 1992;285:181-190). The failure torestore the native anatomic relationships and biomechanics to theshoulder joint has proven to result in a significantly lesser functionaland durable outcome (Williams G R, et al. “The effect of articularmalposition and shoulder arthroplasty on glenohumeral translations,range of motion, and subacromial impingement”, J Shoulder Elbow Surg.2001; 10(5):399-409).

Conventional methods of shoulder replacement surgery also havedifficulty gaining access to the glenoid joint surface. The glenoidsurface of the shoulder joint is best prepared by working along an axisperpendicular to its surface. Because the humeral head sits in the way,this is a nearly impossible task with conventional methods. The humeralhead has to be partially removed, the subscapularis (anterior shoulderrotator cuff muscle) transected, and the proximal humerus dislocated toeven get close to working along this axis. Because of this difficulty, amajority of orthopaedic surgeons still choose not to replace the glenoidsurface despite clinically proven results of improved pain relief andfunction for shoulder replacement surgery when both the humeral andglenoid surfaces are replaced. (Boyd A D, Thomas W H, Scott R D, et al.“Total shoulder arthoplasty versus hemiarthroplasty—indications forglenoid resurfacing”, J of Arthroplasty 1990;5(4):329-336; Gartsman G M,Roddey T S, Hammerman S M. J Bone Joint Surg 2000;82A(1):26-34; EdwardsT B, Kadakia N R, Boulahia A, et al., “A comparison of hemiarthoplastyand total shoulder arthroplasty in the treatment of primary glenohumeralosteoarthritis: Results of a multicenter study”, J Shoulder Elbow Surg2003; 12(3):207-13; Orfaly R M, Rockwood Calif., Esenyel C Z, et al., “Aprospective functional outcome study of shoulder arthoplasty forosteoarthritis with an intact rotator cuff”, J Shoulder Elbow Surg2003;12(3):214-21.)

Despite improved results of conventional methods when both the humerusand glenoid surfaces are replaced, there still remains limitations withregard to glenoid fixation and early glenoid implant loosening (BoileauP, Avidor C, Krishnan S G, et al., “Cemented polyethylene versusuncemented metal-backed glenoid components in total shoulderarthroplasty: a prospective, double-blind, randomized study”, J ShoulderElbow Surg 2002;11(4):351-9.). Both, cemented polyethylene and metalbacked glenoid components are used in conventional methods. The cementedimplant never incorporates with the glenoid bone and with time, thecement-bone interface eventually fails and the implant comes loose.Conversely, the metal-backed glenoid prosthesis has an unacceptable rateof early loosening, at least 20% in one study. However, if themetal-backed implant can remain rigidly fixed to the bone for asufficient period of time, the bone of the glenoid will eventuallyadhere to the metal-backed surface and long-term studies have revealedlittle evidence for late clinical loosening in these cases. Failure ofthe metal-backed glenoid implant appears to be related to thelimitations in achieving sufficiently rigid and durable initialfixation.

While performing shoulder replacement surgery for arthritis, associatedrotator cuff tears are sometimes discovered and should be repaired whenpossible. If a less invasive surgical approach is employed to performthe shoulder replacement surgery, a less invasive method of rotator cuffrepair that is compatible with the method shoulder replacement surgerymust be to be available to simultaneously address these associatedrotator cuff tears.

BRIEF SUMMARY OF THE INVENTION

One aspect of the present invention regards a method for shoulderreplacement surgery. Utilizing the method of the present invention, aportal is created along a central axis of a neck of a proximal humerusthat is associated with a shoulder of a patient. An implant issubsequently implanted into the shoulder of the patient, however acomponent of that implant is not passed through the portal. The rotatorcuff is spared in the process.

One advantage provided by the above mentioned aspect of the presentinvention is that it allows determination of a central axis in theproximal humerus which allows simple and less invasive perpendicularaccess to the humeral and glenoid joint surfaces. An additionaladvantage is it offers a simple and reliable means of restoring thenative anatomy and biomechanical relationships, allowing for an improvedfunctional and durable outcome.

A further advantage is that it spares the rotator cuff tendons andallows for a quicker and more functional recovery.

Another aspect of the present invention regards a humeral implant withone component that is removably attached to a second component.

Another aspect of the present invention provides a glenoid implant. Theglenoid implant includes an ingrowth shell, a wear-resistant surfacethat is removably attached to the ingrowth shell. An advantage is thatthe ingrowth shell provides novel geometry and superior fixation to theglenoid.

An additional aspect of the invention regards a transhumeral portalsleeve with a bullet shaped guide that has a central and a peripherallongitudinal cannulation. An advantage is that it safely creates aworking portal along the central axis of the proximal humerus.

In another aspect of the present invention, there is provided atranshumeral humeral reamer that has a working head and a removablyattached transhumeral shaft with a diameter of from 0.1 to 5 cm.

Another aspect of the present invention regards a transhumeral glenoidreamer with a working head and a removably attached transhumeral shaftthat has a diameter of from 0.1 to 5 cm.

In another aspect, a transhumeral protective sheath is provided that isa tube of material with a diameter of from 0.1 to 5 cm.

Another aspect of the invention regards a glenoid surface protectiveguard that has a protective surface and a removably attached handle.

In another aspect, a humeral head surface protective guard is providedthat has a protective surface and a removably attached handle.

An additional aspect of the invention regards a glenoid sizer andcentering hole guide that has a surface that contacts the glenoid of ashoulder and a removably attached handle.

In another aspect, a drill guide with a guiding surface and a removablyattached handle is provided. The guiding surface has a centering holeand is available in sizes equivalent to the respective glenoid implants.

In another aspect, the invention regards a transhumeral glenoid drillwith a working surface and a removably attached shaft.

In another aspect, a transhumeral burr is provided. The transhumeralburr has a high speed working burr surface and a removably attachedshaft.

An additional aspect of the invention regards a glenoid keel punch witha working head and a removably attached shaft. The working head has akeel shape and cutting teeth.

In another aspect, a transhumeral irrigation and suction catheter isprovided. The catheter is a semi-rigid plastic tubing removably attachedto either a fluid pump or a suction device.

In another aspect, a transhumeral cementation device is provided thathas a semi-rigid catheter removably attached to a head.

An additional aspect provides a transhumeral glenoid impactor with adome-shaped head and a removably attached shaft.

Another aspect of the invention regards a transhumeral screw driver witha working head and a removably attached shaft.

In another aspect, the present invention provides a rotator intervalretractor with a first blade dimensioned to interact with asupraspinatus and a second blade dimensioned to interact with asubscapularis.

Another aspect of the invention regards a glenohumeral joint with atranshumeral portal along a central axis of a neck of a proximal humerusas well as an implant.

Further advantages as well as details of the present invention ensuefrom the following description of a preferred embodiment represented inthe drawings.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a schematic of a patient positioned with fluoroscopy C-armunit that may be used in conjunction with the present inventions;

FIGS. 2a and b are plan views of an embodiment of a rotator intervalretractor with specialized supraspinatus and subscapularis blades (FIG.2b ) in accordance with the present invention;

FIG. 3a is a perspective view of an embodiment of a transhumeral portaldrill guide and protective sleeve in accordance with the presentinvention.

FIG. 3b is a top plan view of the transhumeral portal drill guide ofFIG. 3 a;

FIG. 3c is a side plan view of the protective sleeve of the transhumeralportal drill guide and sleeve of FIG. 3a in accordance with the presentinvention;

FIG. 4a is a schematic of an embodiment of an insertion procedure of aproximal humeral guide pin and measurement of humeral head depth-afterplacement of a second guide pin in accordance with the presentinvention;

FIG. 4b is a schematic of the insertion of FIG. 4a using an optionalembodiment of a radiolucent guide attachment to assist with a guide pininsertion procedure in accordance with the present invention;

FIG. 5 is a schematic of an embodiment of a drilling procedure forforming an embodiment of a transhumeral portal in accordance with thepresent invention;

FIG. 6 is a schematic of a preliminary cut of a humeral head jointsurface during an embodiment of a surgical procedure in accordance withthe present invention;

FIG. 7a is a schematic showing a possible way of preparing the humeralhead with a transhumeral humeral head reamer in preparation for aconventional proximal humeral implant during an embodiment of a surgicalprocedure in accordance with the present invention;

FIG. 7b is a schematic showing a possible way of preparing the humeralhead with a novel transhumeral humeral reamer in preparation for a novelproximal humeral implant during an embodiment of a surgical procedure inaccordance with the present invention;

FIG. 7c is a perspective view of an embodiment of a novel transhumeralhumeral reamer head to be used in an embodiment of a surgical techniquein accordance with the present invention;

FIG. 7d is a perspective view of an embodiment of a glenoid protectivecap to be used in an embodiment of a surgical technique in accordancewith the present invention;

FIG. 8a is a schematic showing a possible way of drilling a glenoidcentering hole and placing a transhumeral glenoid guide wire with aglenoid sizing and centering guide which can be used for both a left anda right shoulder for a conventional proximal humeral implant in anembodiment of a surgical procedure in accordance with the presentinvention;

FIG. 8b is a schematic showing a possible way of drilling a glenoidcentering hole and placing a transhumeral glenoid guide wire with aglenoid sizing and centering guide which can be used for both a rightand a left shoulder for a novel proximal humeral implant during anembodiment of a surgical procedure in accordance with the presentinvention;

FIG. 8c is a perspective view of an embodiment of a head of a glenoidsizing and centering guide in accordance with the present invention;

FIG. 9a is a schematic of a way of preparing a glenoid with a cannulatedtranshumeral glenoid reamer for conventional proximal humeral implantduring an embodiment of a surgical technique in accordance with thepresent invention;

FIG. 9b is a schematic of a way of preparing a glenoid with a cannulatedtranshumeral glenoid reamer for a novel proximal humeral implant duringan embodiment of a surgical technique in accordance with the presentinvention;

FIG. 10a is a schematic of a way of preparing a glenoid with atranshumeral glenoid keel/peg drill and a glenoid peg or keel guide fora conventional proximal humeral implant during an embodiment of asurgical technique in accordance with the present invention;

FIG. 10b is a perspective view of a peg or keel guide for a conventionalglenoid implant to be used in an embodiment of a surgical technique inaccordance with the present invention;

FIG. 10c is a schematic of a way of preparing a glenoid with atranshumeral keel/peg glenoid drill and a glenoid peg or keel guide fora novel proximal humeral implant during an embodiment of a surgicaltechnique in accordance with the present invention;

FIG. 11a is a schematic of a way of preparing a glenoid to accept aconventional keel glenoid implant with a transhumeral burr for aconventional proximal humeral implant during an embodiment of a surgicaltechnique in accordance with the present invention;

FIG. 11b is a schematic of a way of preparing a glenoid to accept aconventional keel glenoid implant with a transhumeral burr for a novelproximal humeral implant during an embodiment of a surgical technique inaccordance with the present invention;

FIG. 12a is a schematic of a way of preparing a glenoid to accept aconventional keel glenoid implant with a transhumeral keel punch for aconventional proximal humeral implant to be used in an embodiment of asurgical procedure in accordance with the present invention;

FIG. 12b is a schematic of a way of preparing a glenoid to accept aconventional keel glenoid implant with a transhumeral keel punch for anovel proximal humeral implant to be used in an embodiment of a surgicaltechnique in accordance with the present invention;

FIG. 13a is a schematic a way of utilizing an embodiment of atranshumeral cementation catheter and glenoid cement pressurizer for aconventional proximal humeral implant to be used during a surgicalprocedure in accordance with the present invention;

FIG. 13b is a perspective view of an embodiment of a modular glenoidcement pressurizer tip for a keel implant and a catheter in accordancewith the procedure shown in FIG. 13 a;

FIG. 13c is an exploded view of an embodiment of a glenoid cementpressurizer tip of FIGS. 13a and b in accordance with the presentinvention;

FIG. 13d is an exploded view of an embodiment of a glenoid cementpressurizer tip for a peg implant of FIGS. 13a and c , in accordancewith the present invention;

FIG. 13e is a schematic of a way of utilizing an embodiment of atranshumeral cementation catheter and glenoid cement pressurizer for anovel proximal humeral implant to be used during a surgical procedure inaccordance with the present invention;

FIG. 14a a schematic of a way of utilizing an embodiment of atranshumeral glenoid impactor for a conventional humeral implant duringa surgical procedure of the present invention;

FIG. 14b is a schematic of a way of utilizing an embodiment of atranshumeral glenoid impactor for a novel humeral implant during asurgical procedure of the present invention;

FIG. 15a is a exploded view of humeral implant in accordance with thepresent invention;

FIG. 15b is a bottom plan view of a humeral implant in accordance withthe present invention;

FIG. 16 is a schematic of an embodiment of a humeral surface implant,Example A, in accordance with the present invention;

FIG. 17a is schematic of an embodiment of a humeral surface implant,Example B, in accordance with the present invention;

FIG. 17b is a perspective view of an embodiment of a stem with innercement channels in accordance with the present invention;

FIG. 17c is an perspective view of an embodiment of a endcap of thenovel transhumeral stem of FIG. 17b in accordance with the presentinvention;

FIG. 18a is a schematic of a way of removing an embodiment of a humeralsurface implant, Step 1, Example B, during an embodiment of a surgicalprocedure in accordance with the present invention;

FIG. 18b is a schematic of a way of performing Step 2 of removing anembodiment of a humeral surface implant of FIG. 18a during an embodimentof a surgical procedure in accordance with the present invention;

FIG. 19a is a schematic of inserting an embodiment of a humeral surfaceimplant, Example C in accordance with the present invention;

FIG. 19b is a perspective view of a stem of an embodiment of a humeralimplant of FIG. 19a that is inflatable in accordance with the presentinvention;

FIG. 20a is a schematic a way of inserting a multiple peg glenoidsurface to be used in an embodiment of a surgical technique inaccordance with the present invention;

FIG. 20b is a side plan view of a glenoid peg to be used in during asurgical technique in accordance with the present invention;

FIG. 20c is a perspective view of a multiple peg glenoid guide of FIG.20a in accordance with the present invention;

FIG. 21 is a side perspective view of an embodiment of a noveltranshumeral glenoid reamer in accordance with the present invention;

FIG. 22 is a schematic of a way of utilizing a novel glenoid reamer inan embodiment of a surgical technique in accordance with the presentinvention;

FIG. 23a is a perspective view of an embodiment of a shell component ofa novel glenoid implant in accordance with the present invention;

FIG. 23b is a bottom plan view of a shell component of a novel glenoidimplant of FIG. 23 a;

FIG. 24a is a schematic of a way of drilling screw holes into a glenoidutilizing a glenoid drill guide sleeve and glenoid screw guide sleeve inan embodiment of a surgical technique of the present invention;

FIG. 24b is an exploded view of the glenoid drill guide sleeve interfitwith the glenoid screw guide sleeve of FIG. 24 a;

FIG. 25a is a schematic of a way of utilizing a glenoid screw guidesleeve and transhumeral screwdriver in accordance with an embodiment ofa surgical technique of the present invention;

FIG. 25b is an exploded view of the glenoid screw guide sleeve of FIG.25 a;

FIG. 26a is a schematic of utilizing a transhumeral impactor to secure anovel wear-resistant glenoid surface into an ingrowth shell of the novelglenoid implant in accordance with an embodiment of the presentinvention;

FIG. 26b is an exploded view of the novel glenoid implant of FIG. 26 a;

FIG. 27a is a side view of an embodiment of a novel glenoid implant inaccordance with the present invention;

FIG. 27b is a top plan view of an embodiment of a novel wear-resistantsurface the novel glenoid implant of FIG. 27 a;

FIG. 27c is a bottom plan view of an embodiment of the novelwear-resistant surface of novel glenoid implant of FIGS. 27a and b.

FIG. 28a is a perspective view of an embodiment of an insertional guidein accordance with the present invention;

FIG. 28b is a perspective view of an embodiment of a flexible innertrocar of an embodiment of an insertion guide in accordance with thepresent invention;

FIG. 29 is a perspective view of an embodiment of a suture pin of thepresent invention;

FIG. 30 is a schematic of a way of performing an embodiment of asurgical technique using the insertion guide of FIGS. 28-29 to bore intoa greater tuberosity of proximal humerus in accordance with the presentinvention;

FIG. 31 is a schematic of a way of performing an embodiment of asurgical technique using the insertion guide of FIGS. 28-29 to advancethe suture-pin device through the greater tuberosity of the proximalhumerus and leading edge of rotator cuff tendon in accordance with thepresent invention;

FIG. 32 is a schematic of a way of performing an embodiment of asurgical technique using a pin director to guide the pin out from theshoulder in accordance with the present invention

FIG. 33 is a schematic of a way of performing an embodiment of asurgical technique and tying the passed suture of the suture pin deviceafter removing the pin component in accordance with the presentinvention.

DETAILED DESCRIPTION OF THE DRAWINGS AND THE PRESENTLY PREFERREDEMBODIMENTS

The present invention relates to methods, instrumentation, and implantsfor performing rotator cuff sparing shoulder replacement surgery. Both,total shoulder arthroplasty, where both the humeral and glenoid jointsurfaces are replaced, and shoulder hemiarthroplasty, where only thehumeral joint surface is replaced, can be performed as indicated. Thepresent invention utilizes among other things: a novel surgical exposureincluding an optional method of arthroscopic anterior contracturerelease, posterior capsular tightening, osteophyte resection, andglenoid soft-tissue clearance; two limited incisions, a transhumeralportal and a deep rotator cuff sparing exposure; novel transhumeralinstrumentation with modular working components, protective guides,sleeves, sheaths, and retractors; conventional or novel implants, and anassociated method of rotator cuff repair.

Utilizing the method of the present invention, a portal is created alonga central axis of a neck of a proximal humerus that is associated with ashoulder of a patient. This portal provides superior perpendicularaccess to both the humeral and glenoid joint surfaces in a less invasivemanner to allow more anatomic replacement surgery to occur. The axis ofthe humeral head and the axis of the glenoid have a sufficientlyconsistent natural relationship such that simple positioning of the armcan allow a surgeon to easily align the central axis perpendicular tothe humeral head with the axis perpendicular to the glenoid. Researchhas shown that there exists a natural relationship between theorientation of the humeral and glenoid surfaces (De Wilde, L F, et al.,“Glenohumeral Relationship in the Transverse Plane of the Body”, JShoulder Elbow Surg 2003;12(3):260-267). Therefore, I have determinedthat with consistent positioning of the arm, these axes will beco-linear.

Accordingly, the present invention provides a reliable way ofreestablishing the proper orientation of the humeral and glenoid jointsurfaces without the associated surgical morbidity of conventionalmethods, i.e., a large exposure, dislocation of the humerus, ortransection of the rotator cuff, as will be described below. Note thatin the description to follow there will be mention made of transhumeralinstruments. Such transhumeral instruments include transhumeral proximalhumerus and glenoid reamers, drills, burrs, guides, protective guards,sheaths, sleeves, cementation tools, glenoid peg and keel punches, andglenoid implant insertor and impactor.

Shown in FIGS. 4a-b , 5, 6, 7 a-b, 8 a-b, 9 a-b, 10 a-c, 11 a-b, 12 a-b,13 a, 13 e, 14 a-b, 16, 17 a, 18 a-b, 19 a, 20 a, 22, 24 a, 25 a, and 26a, is a possible medical procedure according to the present invention.Preoperatively, two orthogonal radiographic images should be takenincluding a Grashey anteroposterior view with the patient's shoulderheld in neutral rotation to slight external rotation and an axiliarylateral view. Next, two-dimensional transparencies with representationsof different sizes of the humeral and glenoid implants/templates areplaced over the x-rays to evaluate the patients bony anatomy andestimate the size of the implants to be used. From these radiographicimages, preoperative measurements can be taken of the humeral headdiameter and depth, the humeral neck angle, glenoid size and version,and the amount of scapular bone available to fix the implants to be usedin the surgical procedure. A preoperative CT scan of the shoulder canalso be useful when plain radiographs do not offer sufficient detail.

After interscalene regional block and general anesthesia areadministered by the anesthesiologist, the patient 1 is positioned in asitting position with a beach chair positioner 3 as shown in FIG. 1.Prior to prepping and draping the patient 1, a fluoroscopic C-armmachine 7 is positioned accordingly to the patient 1 to obtain a Grasheyanteroposterior radiographic view and a modified axiliary lateral viewusing rotation of the shoulder and slight repositioning of thefluoroscopic machine 7. After the fluoroscopic views are confirmed, thefluoroscopic machine 7 is backed away from the patient 1 and theshoulder and upper extremity are prepped and draped in sterile fashion.

Initially, an optional arthroscopic procedure may be performed usingconventional arthroscopic tools to release the anterior capsularcontractures, tighten the posterior capsule, resect osteophytes, andclear the glenoid soft-tissue for exposure. The procedure is begun byplacing an arthroscope in the shoulder joint through a standardposterior portal and making an anterior rotator interval passage underneedle localization. Standard diagnostic arthroscopy is performed andthe posterosuperior, superior, and anterior labrum are excised orablated; the biceps tendon may be released from the superior glenoid;and the anterior and anteroinferior ligamentous and capsular attachmentsare released from the glenoid. Then an accessory posterior passage ismade under needle localization and an arthroscopic burr is inserted toremove the inferior humeral neck osteophytes. From the same accessoryposterior passage, the posterior, posteroinferior and inferior labrumare excised or ablated and the posteroinferior and inferior ligamentousand capsular attachments to the glenoid are released from 7 O'clockanteriorly on a right shoulder or 5 O'clock anteriorly on a leftshoulder. Gentle manipulation of the shoulder can also be performed ifnecessary to complete the soft-tissue release. Any posterior capsularredundancy can be addressed by techniques of capsular plication(tightening with arthroscopic sutures).

After the optional arthroscopic procedure is performed, ananterosuperior passage is formed to expose the glenohumeral joint. Inparticular, an anterosuperior incision is made either obliquely runningover the anterolateral border of the acromion over the tip of thecoracoid or longitudinally from just inferior to the clavicle runningbetween the coracoid and the AC joint distally. Deep dissection iscontinued through the deltopectoral interval or a limited muscular splitrunning in line with the deltoid muscle fibers. The clavipectoral fasciais incised, the coracoacromial ligament is released from the coracoid,and the subdeltoid and subacromial adhesions are released. Bony andsoft-tissue subacromial decompression and distal clavicle excisionshould be performed if secondary conditions of impingement, rotator cufftears, or acromioclavicular joint arthritis are present. The anteriorcircumflex blood vessels are ligated only as needed. The rotatorinterval is opened completely around both sides of the coracoid anddistally into the biceps sheath. The supraspinatus and subscapularismuscles are bluntly released from the glenoid superior and anteriorsurfaces, respectively. A biceps tenodesis may be performed by simplysewing it to the tissue of the biceps sheath and excising theintraarticular portion of the tendon. At this point, a novel rotatorinterval retractor 5 with specialized supraspinatus 2 and subscapularis4 blades is inserted (FIGS. 2a-b ). The blades connect to separate armsof a self-retaining device which allow it to hold open the intervalbetween the supraspinatus and the subscapularis rotator cuffmusculotendinous units.

If necessary, a secondary rotator interval can be made by splitting thesubscapularis in line with its fibers.

Note, that the anterosuperior passage described above and below can beperformed without the aid of the previously described arthroscopicprocedure. If the arthroscopic procedure is not performed, jointcapsular contractures are released, posterior capsule is tightened (ifneeded), osteophytes are resected, and the soft-tissue surrounding theglenoid is excised as described above using open rather thanarthroscopic instruments.

The surgical method next involves creating a transhumeral portal 30. Thetranshumeral portal 30 is a cylindrical-like tunnel that is parallel tothe neck of the humerus from the anterolateral bony cortex of theproximal humerus through the center of the humeral head. Creation of thetranshumeral portal 30 first involves obtaining an anteroposterior viewof the proximal humerus via the fluoroscopic C-arm machine 7 shown inFIG. 1. The shoulder is externally rotated between 20 and 40 degreesrelative to the plane of the fluoroscope 7 to achieve a viewperpendicular to the neck of the humerus. A free radioopaque guide pinis placed over the anterior shoulder along the axis of the humerus neck.By using fluoroscopy, a guide pin in that position defines a line to beused as a guideline that is marked/drawn along the anterior skin. Asecond small anterosuperior incision is made longitudinally, 1centimeter lateral to the biceps tendon centered on the point ofintersection with the drawn guideline marking the humeral neck axis.This second incision lies just inferolateral to the first. Via thesecond anterosuperior path, the deep deltoid muscle is split bluntlyalong its fibers to protect the motor branch of the axillary nerve andthe transhumeral portal drill guide 14 and protective sleeve 15 (FIGS.3a-c ) are inserted down to the anterolateral cortex of the humerus,approximately 1 cm lateral to the biceps groove. Using intraoperativefluoroscopy, a small guide pin 16 is inserted through the transhumeralportal drill guide 14 and sleeve 15 from the anterolateral humeralcortex along the central axis of the humeral neck into the center of thearticular surface of the humeral head (FIG. 4a ). Anteroposterior andmodified axillary lateral fluoroscopic images are taken to confirmproper positioning of the guide pin 16. The guide pin 16 is repositionedas necessary until the pin runs centrally through the humeral neck andhead on all fluoroscopic views.

Note, a specialized transhumeral portal drill guide 14 may be used tohelp direct the guide pin 16 into the center of the humeral head 20(FIG. 4a ). The transhumeral portal drill guide 14 is a bullet shapedobject with multiple longitudinal cannulations to direct guide 16, 18 .It fits into a protective sleeve 15 which has a handle 6 that isinserted into the second anterosuperior passage to the anterolateralcortex of the proximal humerus 20. This sleeve 15 and guide 14 protectthe surrounding soft-tissue and axillary nerve from harm. There is aradiolucent guide attachment 21 which rigidly connects to the handle 6of the protective sleeve 15 of the transhumeral portal drill guide 14.The radiolucent guide attachment 21 has a radiolucent arm 23 which runsparallel with the cannulations 10,12 in the transhumeral portal guide 14and connects to a radiolucent tip 25 which can be any suitable shape,for example, hemispheric (FIG. 4b ). Once the guide is assembled, thecentral cannulation 12 of the transhumeral portal guide 14 will direct aguide pin 16 to the center of the hemispheric tip 25. The arm 23 of theguide attachment 21 is sufficiently long to allow significantadjustments in length to accommodate variations in size of the proximalhumerus. After the tip 25 of the transhumeral portal drill guide 14 isplaced on the humeral surface through the first anterosuperior passage,the radiolucent arm 23 containing a radiopaque reference line can alsobe aligned with the central axis of the neck of the proximal humerus 20under fluoroscopy to assist in directing the guide pin 16 to the centerof the humeral 20 surface.

The guide pin 16 is advanced through the transhumeral drill guide 14 andprotective sleeve 15 such that it travels toward the glenohumeral joint9, along the central axis of the neck of the humerus and perpendicularto the humeral 20 joint surface. The guide pin 16 is advanced such thatthe tip of the pin stops right at the humeral 20 joint surface. A secondpin 18 of equal length is inserted through one of the peripheral holes10 in the transhumeral portal drill guide 14 and sleeve 15 until itstops at the lateral humeral cortex. Measuring the difference in exposedlength between the pins 16,18 closely estimates the length of thetranshumeral portal 30. This measurement assists the surgeon in creatingand using the transhumeral portal 30 more safely as well as providingthe size of the modular stem 98 used for the proximal humeral implant94. Then, the second guide pin 18 is advanced into the bone until itreaches the level of the anatomic neck 13 of the humerus. Measuring thedifference in exposed length between the pins 16, 18 provides anaccurate measurement of humeral head 20 depth (FIGS. 4a-b ). Using theactual humeral depth measured by the difference between the pins, 16, 18and that measured on the fluoroscopic screen, the actual humeral headdiameter can be determined from measurements on the fluoroscopic screen.These measurements help in selecting the proper size transhumeralhumeral reamers and final humeral implant later in the procedure.

Based on the actual measured transhumeral portal 30 length, thetranshumeral portal 30 is created by drilling with an approximately 1centimeter diameter or less cannulated drill bit 26 through thetranshumeral portal protective sleeve 15 over the first guide pin 16from the anterolateral humeral cortex and into the joint (FIG. 5). Thetranshumeral portal 30 defines an opening of any suitable shape (such ascircular, square, triangular, etc), having a diameter with a range of0.1 to 5 cm, more preferably, a range of 0.1 to 1 cm, and mostpreferably, a range of 0.5 to 1.0 cm. The first guide pin 16 is removedalong with the cannulated drill bit 26 and the second guide pin 18 mayremain as a guide for later humeral head resection.

With the formation of the transhumeral portal 30, the humeral 20 andglenoid 22 surfaces can be prepared as explained hereafter. Note thatthe order of preparing either the humeral 20 or glenoid 22 surfaces maybe altered depending on the proximal humeral 20 bone quality. If thereare concerns about the quality of the proximal humeral 20 bone, thehumeral 20 surface can be prepared last, after the glenoid 22, to avoidweakening the proximal humeral bone 20 and jeopardizing the integrity ofthe transhumeral portal 30. Also, if hemiarthroplasty is indicated, thehumeral 20 surface may solely be prepared and replaced.

Assuming that it is determined to prepare the humeral 20 surface first,the articular surface of the humeral head 20 may either be resected andreplaced to the level of the anatomic neck 13 for the insertion of aconventional proximal humeral implant, or merely resected and replacedto the level of the subchondral bone for the insertion of a novelproximal humeral implant 94. To insert a conventional humeral implant inaccordance with the present invention, a preliminary humeral head 20 cutcan be made to improve visualization and expedite resection. From theanterosuperior passage previously formed, a long oscillating saw 28 isused to safely resect a limited portion of the humeral head 20 jointsurface perpendicular to the portal (FIG. 6).

A transhumeral protective sheath 38 used during the procedure of thepresent invention is then threaded or press-fit into the transhumeralportal 30 through the second anterosuperior passage using thetranshumeral portal drill guide protective sleeve 15 to safely directit. It is inserted to the level of the anatomic neck 13 of the proximalhumerus 20 in preparation for a conventional humeral implant or to thelevel of the humeral 20 joint surface for a novel humeral implant 94(FIG. 7a ). An embodiment of the transhumeral protective sheath 38 ofthe present invention provides protection for the bone within which thetranshumeral portal sits. The transhumeral sheath 38 is a tube of suchshape, inner and outer diameter, and thickness such that it interfitssecurely within the transhumeral portal 30 along the central axis of theneck of the humerus 20, allows easy passage and use of all transhumeralinstruments and sleeves while protecting the remaining bone of theproximal humerus 20 from harm. The transhumeral sheath 38 may be metal,plastic, or other semi-rigid, wear-resistant material and may be slid orthreaded into the transhumeral portal.

Next, a transhumeral reamer shaft 34 is placed through the protectivesheath 38 and assembled in the joint with the appropriately sizedmodular humeral reamer head 36 inserted through the anterosuperiorpassage (FIGS. 7a-d ). A novel transhumeral humeral reamer 32, in oneembodiment of the present invention, includes a reaming surface 36 and atranshumeral shaft 34. The transhumeral reamer 32 is designed so thatthe shaft 34 interfits securely within the transhumeral portal 30, andmore specifically, within the transhumeral protective sheath 38 withinthe transhumeral portal 30, such that there is no shaking or togglingwhile the reamer is being used. Therefore the diameter of the shaft 34is from 0.1 to 5 cm and slightly smaller than the inner diameter of thetranshumeral protective sheath 38 through which it traverses. For aconventional humeral prosthesis, a flat reaming head surface 36 withsizes similar to the diameter of the humerus and surgical neck are used.The flat reamer removes bone of the humeral head down to the level ofthe anatomic neck 13 of the humerus. For a novel humeral implant 94, ahemispherically shaped reaming surface 37, sized similarly to a novelhumeral surface 96 implant component is used, having similar depth andradius of curvature (FIG. 7c ). The hemispherically shaped reamingsurface 37 removes a minimal amount of bone. The amount of bone removedis roughly equivalent to the thickness of the humeral surface 96component of the implant 94.

A protective guard 40 may be placed over the glenoid through theanterosuperior passage during reaming (FIG. 7d ). The protective guard40 is introduced through the first anterosuperior passage by a handle44. In one embodiment of the present invention, the guard 40 is shapedlike the glenoid and is available in small, medium and large sizes. Theguard is made of a solid metal surface with an elevated peripheral edgethat fits over the glenoid surface. The guard has a thickness of about0.1 to 2 mm. The handle 44 is removable and can be attached to the guardat different positions to allow it to be inserted from variable anglesthrough the anterosuperior passage.

After the guard 40 is in place, the orthopaedic surgeon grasps theprotective sheath 38 and pulls the running reamer 32 back onto thehumeral head until it cuts to the level of the anatomic neck 13 for aconventional humeral implant (FIG. 7a ). Live fluoroscopy may be used toassist with making the cut and insuring that the reamer stays parallelto the second guide pin 18 and stops before its tip. The bone debrisfrom the cutting is removed with thorough irrigation from theanterosuperior passage. Any remaining humeral osteophytes may be removedwith a small rongeur from the anterosuperior passage.

To insert a novel proximal humeral implant 94, the transhumeralprotective sheath 38 and reamer shaft 34 are inserted as described above(FIGS. 7a-d ). Alternatively, the appropriate size novel modular humeralreamer head 37 is inserted through the anterosuperior passage into thejoint and assembled with the transhumeral shaft 34. A protective guard40 may be placed over the glenoid 22 through the anterosuperior passageduring reaming. Again, the orthopaedic surgeon grasps the protectivesheath 38 and pulls the running reamer 32 back onto the humeral headuntil the novel humeral reamer has removed just enough bone to restorethe proper humeral head dimensions (FIG. 7b ). Openings 39 in the reamerhead can help the surgeon determine the proper amount reaming. Also,live fluoroscopy may be used to assist with making the cut and insuringthat the reamer 32 stays parallel to the second guide pin 18 and stopsat the appropriate level. The bone debris from the cutting is removedwith thorough irrigation and suction from the anterosuperior passage.Any remaining humeral osteophytes may be removed with a small rongeurfrom the anterosuperior passage.

After the reamer 32 has prepared the humeral head, either for aconventional or a novel proximal humeral implant 94, the glenoid 22 ofthe shoulder joint can then prepared for the placement of a conventionalglenoid implant 115 (FIG. 8a ). Any remaining soft-tissue obstructingthe glenoid surface 22 should be excised. The humerus is abducted,rotated, and laterally distracted to direct the transhumeral portal 30such that its path lies perpendicular to and centered on the glenoidsurface 22. A glenoid sizing and centering hole guide 46 is placed fromthe anterosuperior passage (FIGS. 8a-c ). In another embodiment of thepresent invention, a glenoid sizer and centering hole guide 46 includesa working surface 52 and a handle 53. The guide 46 is shaped and sizedaccording to the shape and size of the glenoid 22 to be prepared. Theworking surface 52 is inserted through the first anterosuperior passageby its handle 53. The handle 53 is removable and can be attached to theworking surface 52 at different positions 56 to allow it to be insertedfrom variable angles through the anterosuperior passage. The workingsurface 52 is approximately 0.1 to 10 mm thick and flat and has acentral hole 54.

Utilizing the appropriately sized glenoid sizing and centering guide 46,a transhumeral guide wire 50 is inserted into the transhumeral portal 30through the transhumeral protective sheath 38 to drill a centering holein the glenoid surface 22 regardless of whether a conventional or novelhumeral implant is being inserted (FIGS. 8a-b ). After the centeringhole has been started, the guide wire 50 is backed up to allow theremoval of the glenoid sizing and centering guide 46. A cannulated flator hemispherical humeral head guard 64, followed by a cannulated glenoidsurface cutting reamer head 60, is inserted through the anterosuperiorpassage and the guidewire 50 is advanced through cannulations in bothinstruments back into the centering hole in the glenoid.

In another embodiment of the present invention, a humeral head surfaceprotective guard 64 may be used (FIGS. 9a-b ). This protective guard 64includes a protective metal surface which is flat or hemispheric inshape corresponding to the prepared end of the proximal humerus for aconventional or novel humeral implant, respectively. The protectiveguard 64 is inserted via the first anterosuperior passage and fits overthe humeral surface 20 and the shaft 62 of the transhumeral glenoidreamer 58. The shaft 62 of the transhumeral glenoid reamer 58, describedbelow, passes through a central cannulation of the guard 64 to preparethe glenoid 22. The humeral head surface protective guard 64 is sizedaccording to need, such as small, medium, and large. The guard 64 isapproximately 0.1 to 2.0 mm thick. Optionally, the guard 64 may be usedwith a handle.

The present invention also provides a transhumeral glenoid reamer 58(FIGS. 9a-b , 21, 22, 23 a-b). The glenoid reamer 58 has a shaft 62 anda working head 60. The shaft 62 is designed to interfit securely withinthe transhumeral portal 30, and more specifically, within thetranshumeral protective sheath 38 within the transhumeral portal 30,such that there is no shaking or toggling of the shaft 62 within thetranshumeral portal 30 while the transhumeral glenoid reamer 58 is inuse. Therefore, the outer diameter of the shaft 62 is approximately 0.1to 5 cm, and slightly less than the inner diameter of the transhumeralprotective sheath 38 within which the shaft 62 is used. The workingglenoid reamer heads 60, 61 and shaft 62 are cannulated to fit over acentral glenoid guide wire 50. There is also a non-cannulated reamerhead with a leading central peg which can fit into a central glenoidhole and allow some redirection of the reamer as necessary.

For a conventional glenoid implant 115 (shown in FIG. 14a ), a nearlyflat, slightly convex, reaming head surface 60 is used with sizes beingsimilar to that of a glenoid. The radius of curvature of the reamersurface matches that of the non-articular side of the conventionalglenoid implant. The flat reaming head 60 removes a minimal thickness ofbone. The same flat reaming head 60 as used for a conventional glenoidimplant 115 may also be used before inserting the multiple peggedglenoid implant 117.

For a novel glenoid implant 118, the glenoid reamer head 61 includes aperipherally flat, less aggressive surface 116 and a centrally raisedsurface 114 which has a more aggressive reaming surface (FIG. 23a-b ).The centrally raised surface 114 may be a convex dome, a square,triangle, pyramid, or any other shape that matches the protrudingsurface of the novel glenoid implant 118 to be implanted within theglenoid, as described below. The peripheral glenoid reaming surface 116removes a minimal amount of bone from the peripheral surface of theglenoid to just correct the version (orientation) of the glenoidsurface. In one embodiment, the central reaming surface 114 removes aspherically shaped area of bone such that a central concave glenoidsurface is created which fits an ingrowth shell component 120 of a novelglenoid implant 118 in accordance with the present invention. Theconcavity is slightly undersized to allow a pressfit of the ingrowthshell 120.

To prepare the glenoid 22 for a conventional prosthesis 115, thecannulated transhumeral glenoid reamer shaft 62 is positioned over theguidewire 50 and through the transhumeral protective sheath 38 from thesecond anterosuperior passage. The transhumeral reamer shaft 62 isassembled in the shoulder joint with its glenoid surface cutting reamerhead 60 and the reamer 58 is advanced along the guide wire 50 removingas little bone as possible to correct the profile of the worn glenoid 22and create the proper radius of curvature on the surface to match thatof the non-articular surface of the conventional glenoid implant 115.The guide wire 50 must be inserted initially in the proper orientationto direct the cut appropriately. There is also an optional glenoidcutting surface head with a central peg that can be used without theguidewire 50 and can be inserted directly into the glenoid centeringhole while the surgeon runs the transhumeral glenoid reamer 58 (FIG. 9a,b ). The bone debris from the cutting is removed with thoroughirrigation from the anterosuperior passage. Any remaining glenoidosteophytes may be removed with a small rongeur from the anterosuperiorpassage.

The glenoid 22 can be prepared for implantation of either a conventionalpegged or keeled glenoid implant 115, a multiple peg glenoid implant 117(FIG. 20b ), or a novel glenoid implant 118. In the case of implanting aconventional peg or keel glenoid implant 115, the appropriately sized(according to the previously used glenoid sizer and centering holeguide), peg glenoid or keel guide 68 is inserted through theanterosuperior passage and centered by placing its peg 72 into thepreviously created glenoid centering hole (FIG. 10a ). The transhumeralglenoid drill 66 is placed through the transhumeral protective sheath 38within the transhumeral portal 30 from the second anterosuperiorpassage. In one embodiment of the present invention, a glenoid keeldrill guide 68 has a working surface 69 and a handle 70. The workingsurface 69 is introduced via the first anterosuperior passage by itshandle 70. The handle 70 is removable and can be attached to the guide68 at different positions to allow it to be inserted from variableangles through the anterosuperior passage. This drill guide 68 is shapedand sized similarly to the glenoid sizing and centering hole guide 46,discussed above. The working surface 69 of the guide 68 has a centralpeg 72 that fits into a centering hole in the glenoid bone. The drillguide 68 for the conventional keel glenoid implant has two convergingholes, one superior and one inferior, directed toward each other todirect a transhumeral glenoid drill 66 to cut a keel shape into theglenoid bone (FIG. 10b ).

The previously mentioned glenoid peg drill guide 68 has a workingsurface 69 and a handle 70. The working surface 69 is inserted throughthe first anterosuperior passage by its handle 70. The handle 70 isremovable and can be attached to the guide surface 69 at differentpositions to allow it to be inserted from variable angles through theanterosuperior passage. This drill guide 68 is sized and shapedsimilarly to the glenoid sizing and centering hole guide 46, discussedabove. The working surface 69 of the guide 68 has a central peg 72 thatfits into a centering hole in the glenoid bone. The working surface isapproximately 0.1 to 5 mm thick and has peripheral holes in parallelconfiguration to drill holes with a transhumeral glenoid drill 66 forpegs in a glenoid.

In one embodiment, the above-mentioned transhumeral keel/peg glenoiddrill 66 has a working surface 67 and a removably attached transhumeralshaft 65. The working surface 67 is a drill bit (or tip) for drillingholes in the glenoid for keels or pegs of the conventional glenoidimplant 115. The drill bit 67 (or tip) is larger for drilling holes fora keel or a peg than a bit used for drilling holes for screws.

To further prepare the glenoid surface for a conventional glenoidimplant, the humerus is positioned and translated such that thetranshumeral keel/glenoid drill 66 is maintained perpendicular to theglenoid peg/keel guide surface 69. With the gleonid drill introducedthrough the transhumeral protective sheath 38 of the transumeral portal30 and the glenoid drill guide 68 postioned from the firstanterosuperior passage, holes are drilled into the glenoid (FIGS. 10a-c). To prepare the glenoid to accept a keel glenoid implant, thetranshumeral burr 74 is inserted into the transhumeral portal 30 throughthe transhumeral protective sheath 38 and used to connect the drilledholes in the glenoid 22 surface (FIGS. 11a-b ).

In one embodiment, the transhumeral burr 74 has a transhumeral shaft 75removably attached to a high speed burr tip 73 with different sizes usedfor cutting holes in a glenoid 22, particularly for a keel.

A modular keel punch 76 is used to finish the glenoid keel cut. In anembodiment, where a glenoid keel punch 76 is used, the keel punch 76 hasa working surface 77 and a removably attached transhumeral shaft 78(FIGS. 12a-b ). The working surface 77 (also referred to as a punchhead,) is inserted through the first anterosuperior passage and theshaft 78 is introduced through the second anterosuperior passage and thetranshumeral protective sheath 38. The shaft 78 is assembled with theworking surface 77 in the glenohumeral joint. The working surface 77 isa head shaped like a keel with cutting teeth to cut a keel shape into aglenoid surface 22. The punch 76 is struck with a hammer to complete thekeel shaped cut into the glenoid (FIGS. 12a-b ).

The humeral head and glenoid trial implants are inserted through theanterosuperior passage and the rotator interval retractor 5 (FIG. 2) istemporarily removed. There are different humeral trial implants that canbe used, one for the conventional implant and one for a novel implant.In either case, both can mate with trial modular stems through thetranshumeral portal. If there is not sufficient bone available tostabilize the conventional humeral trial with a transhumeral trial stemor the humeral surface is too far offset from the intramedullary axis ofthe humeral shaft to accurately trial, the intramedullary canal of thehumerus can be prepared and fitted with a conventional intramedullarystem trial using conventional techniques and instruments from theanterosuperior passage. Because the rotator cuff has not beentransected, it is much simpler to determine the proper size implantrequired to restore the normal musculotendinous length and tension inthe rotator cuff and thus, more accurately restore the native anatomicaldimensions of the joint. Fluoroscopy can also be used to judge properimplant size.

Next, the glenoid 22 is prepared to affix its conventional implant 115using transhumeral cementation tools 80 (FIGS. 13a-e ). A transhumeralirrigation and suction catheter is inserted into the transhumeral portal30 through the novel transhumeral protective sheath 38 and used toirrigate and suck the prepared glenoid 22 holes dry. A transhumeralirrigation and suction catheter is used in yet another embodiment of thepresent invention. The irrigation and suction catheter includessemi-rigid tubing that is inserted through the second anterosuperiorpassage and the transhumeral protective sheath 38 in the transhumeralportal 30 in order to irrigate or suction the prepared glenoid surface.The catheter attaches to both, a fluid pump and suction tubing, and maybe easily switched between the two with a stopcock-like device.

The peg or keel holes are temporarily packed with thrombin soaked gelpads or epinephrine soaked gauze using a novel transhumeral forcepsdevice. The transhumeral irrigation and suction catheter is used againto clean and dry the holes and a transhumeral cementation catheter 84 isinserted through the transhumeral portal 30 and protective sheath 38 toplace the cement.

Note that the above-described transhumeral cementation tool 80 includesa keel glenoid or peg glenoid cement pressurizer head 86 and acementation catheter 84. The transhumeral cementation catheter 84includes semi-rigid tubing which connects to a conventional cement gun104 to deliver cement to the site of implant fixation to bone. The head86 includes a keel glenoid or peg glenoid cement pressurizer tip 82 thatis cannulated and fits into a respective keel or peg-shaped preparedhole in the glenoid surface to dispense cementation material underpressure into that hole in the glenoid surface 22. The pressurizer heads86 are shaped similar to a glenoid implant with a smaller keel or singlepeg. The radius of curvature of the periphery of the tip 82 matches thatof the reamed bony glenoid surface 22 to help seal the hole duringcement insertion. These heads 86 are inserted through the firstanterosuperior passage by their handles 88 and are attached to thetranshumeral cementation catheter 84 within the glenohumeral joint 9 topressurize the cement in the glenoid 22 holes. The handle 88 isremovable and can be attached to the head 86 at different positions toallow it to be inserted from variable angles through the anterosuperiorpassage. The cementation head 86 limits the escape of cementationmaterial from the hole and allows pressure to build up which forces thecement deep into the interstices of the trabecular bone to allowimproved fixation. A cement pressurizer tip 82 may be inserted into thejoint through the anterosuperior passage and assembled with thetranshumeral cementation catheter 84. There are different pressurizertips 82 to match either the pegged or keeled glenoid. The conventionalglenoid implant 115 is inserted through the anterosuperior passage, isseated and held in place until the cement dries with a modulartranshumeral glenoid impactor 90. Excess cement is removed and the jointis irrigated

The transhumeral glenoid impactor 90 includes a transhumeral shaft 92which removably attaches to a working head 91. The working head 91 has aconvex surface that approximates the radius of curvature of thearticular surface of the glenoid implant. The shaft 92 is introducedthrough transhumeral protective sheath 38 within the transhumeral portal30. The working head 91 is introduced through the first anterosuperiorpassage and mated with the transhumeral shaft 92. Force can then beapplied to the handle 89 of the impactor 90 to seat the glenoid implant115.

In accordance with an embodiment of the present invention, a multiplepeg glenoid implant 117 (FIGS. 20a-c ) or a novel modular ingrowthglenoid implant 118 (FIGS. 26a-b, 27a-c ) can also be inserted.

After the glenoid surface 22 has been reamed by a glenoid reamer 58 asdescribed previously, the multiple glenoid pegs 17 can be introducedwith a novel multiple peg guide 72 through the anterosuperior passageand inserted into the prepared surface of the glenoid 22 using atranshumeral insertor device 79 (FIG. 20a ). In another embodiment, amultiple peg glenoid insertor 79 and insertor guide 72 are used. Themultiple peg glenoid insertor guide 72 includes a handle 73 and aguiding surface 71. The guiding surface 71 is sized and shaped as theglenoid peg drill guide surface 69 discussed above. The guide 72 isintroduced via the first anterosuperior passage and holds multiple pegs117 to be inserted into the glenoid 22. The guiding surface 71 of theguide 72 controls the depth and location of insertion of the multiplepegs 117.

The multiple peg glenoid insertor 79 is inserted via the secondanterosuperior passage and through the transhumeral protective sheath 38in the transhumeral portal 30. It is used to engage the pegs 117 locatedwithin the multiple peg insertor guide working surface 71 and thendrives them into the glenoid 22 one at a time. The insertor 79 stopswhen it hits the guide surface 71 to control the depth of peg 117insertion. Drilling pilot holes through a separate guide with a specialtranshumeral drill can precede this step. The guide surface 71,preloaded with the implant pegs 117 controls the position, direction anddepth of peg 117 insertion. The guide surface 71 has a protrudingcentering peg which fits into the centering hole of the glenoid to helpcenter and position the guide surface 71.

After the multiple peg prosthesis is implanted, trialing of aconventional or novel humeral implant can be performed as describedpreviously.

Alternatively, a novel ingrowth glenoid implant 118 can be implantedafter reaming the glenoid with a novel transhumeral glenoid reamer 57 asdescribed previously. The novel modular ingrowth glenoid implant 118 hasan ingrowth shell 120 and modular wear-resistant articulating surface122 (FIGS. 23a-b, 26a-b, 27a-c )

The ingrowth shell 120 of the glenoid implant 118 is a cannulatedshallow shell with a protruding surface 119 that sits within theconcavity of the reamed glenoid surface. The protruding surface issurrounded by a flat outer surface 121 (or brim). The protruding surface119 may be any shape such as a square, pyramidal, hemispheric,triangular or any other suitable shape. The protruding surface 119protrudes into the glenoid 22 to a specified depth. The depth is suchthat it is enough for the ingrowth shell 120 to be securely seatedwithin the glenoid 22 and for the wear-resistant surface 122 to fittherein (as described below) and yet not so deep that a large amount ofsubchondral bone must be reamed from the glenoid 22. Preferably, theshape of the previously described novel glenoid reamer 57 is the same asthe shape of the protruding surface 119 of the ingrowth shell 120 suchthat there will be a secure fit when the ingrowth shell 120 is seatedwithin the glenoid 22. As the ingrowth shell 120 is pressed into theglenoid, the flat surface (or annular brim) 121 of the ingrowth shell120 also makes contact with the peripheral glenoid surface 22, and infact, provides a stopping point of insertion. The ingrowth shell 120 ismade of suitable material, examples of which include, but are notlimited to metal, tantalum, porous metal, trabecular metal, ceramicmaterials, and titanium. The protruding surface 119 and the annular brim121 of the shell 120 may also maintain a surface of a bony ingrowthmaterial, as described in connection with the humeral implant below.This ingrowth material promotes bone growth and adhesion of the shell tothe glenoid surface. The ingrowth shell 120 has a thickness of 0.1 to 10mm, preferably from 0.1 to 2 mm. The ingrowth shell 120 has holes forfixation. These holes may be central 124 and peripheral 126 and mayfurther be smooth, threaded or a combination thereof. In one embodiment,a shell has a central hole 124 and multiple peripheral holes 126, forexample three peripheral holes 126. The central hole 124 is preferablysmooth and the peripheral holes 126 are preferably threaded.

After reaming, the ingrowth shell 120 is inserted through theanterosuperior passage and impacted into the concavity (which matchesthe shape of the reamer head 61 and that of the protruding surface 119of the ingrowth shell 120 to be implanted,) of the reamed glenoid with atranshumeral impacting device 90. The concavity is slightly undersizedto attain a tight fit upon impaction. The ingrowth glenoid shell 120 isthen fixed to the glenoid 22 using screws 133, 135. In one embodiment, acentral compression screw 133 is first used to compress the ingrowthshell into the concavity created in the glenoid and affix the ingrowthshell 120 to the glenoid and then fixed angle peripheral screws 135 areused to lock the ingrowth shell into place (FIGS. 25a-b, 26a-b ).

The transhumeral glenoid drill 49 is used along with a transhumeralglenoid drill sleeve 48 (FIGS. 24a-b ) to make the holes for the glenoidscrews 133, 135. The transhumeral glenoid drill sleeve 48 fits into atranshumeral glenoid screw sleeve 128 which fits into the protectivetranshumeral sheath 38 in the transhumeral portal 30. The drill sleeve48 mates with the holes 124, 126 in the ingrowth shell component 120 ofthe novel glenoid implant 118 to direct the drill 49 in the properorientation. The shaft of the transhumeral glenoid drill 49 just fitswithin the inner diameter of the transhumeral glenoid drill sleeve 48and has visible markings on it that allow one to measure the depth ofthe hole off the distant edge of the transhumeral drill sleeve 48 (FIGS.24a-b ). The drill 49 is advanced until the far cortex of the glenoidand scapula is reached. At which point, the surgeon reads the mark onthe drill at the level of the glenoid drill guide sleeve 48.Approximately 5 mm is added to the screw length to determine the lengthof screw used. The drill 49 is then advanced through the far cortex tocomplete the screw hole in the glenoid 22.

In one embodiment of the present invention, a novel transhumeral screwdriver 130 and transhumeral glenoid screw guide sleeve 128 are used toplace the above described screws 133, 135. After drilling, the surgeonremoves the inner transhumeral glenoid drill guide sleeve 48 and thetranshumeral screwdriver 130 is inserted through the previouslypositioned transhumeral glenoid screw guide sleeve 48. The screw drivershaft 130 fits snuggly within a transhumeral glenoid screwdriver guidesleeve 128. The screwdriver 130 is then advanced to place a screw 133,135 through a hole 124 or 126 of the ingrowth shell 120 of a novelglenoid implant 118 into the drilled glenoid bone 22. As brieflydescribed above, a central screw 133 is first inserted through a centralsmooth hole 124 in the glenoid shell 120 to initially compress theingrowth shell 120 firmly into the glenoid surface 22. The glenoidingrowth shell 120 is then locked into place by at least one peripheralscrew 135, preferably three (FIGS. 25a-b, 26a-b ). For example, if threeperipheral screws 135 are utilized, one is placed anterosuperiorly, oneis placed posterosuperiorly, and one is placed inferiorly. The threadsof the screws 135 engage the threading of the peripheral holes 126 inthe glenoid ingrowth shell 120 as well as the drilled outer corticalsurface of the glenoid 22 and scapula. The peripheral holes 126 of theshell 120 direct the screws 135 into a fixed divergent pattern.

After the glenoid ingrowth shell 120 is well fixed, the modularwear-resistant glenoid surface 122 is inserted though the anterosuperiorpassage and impacted into the shell 120 with a transhumeral glenoidimpactor 90 (FIGS. 14a-b, 26a-b ) as described previously.

The wear-resistant surface 122 of the glenoid implant 118 has a convexsurface which mates with the concave side of the protruding surface 119of the ingrowth shell 120 and forms the articulating surface of theglenoid implant 118. The protruding surface 119 of the ingrowth shell120 is of thin dimension such that it simultaneously provides 1)fixation to the glenoid bone; 2) an ingrowth surface; 3) provides asupport surface for the wear-resistant surface 122; and 4) a recessedcoupling device which maximizes the thickness of the wear-resistantsurface 122 for durability and while still maintaining proper anatomicglenohumeral surface relationships. The wear-resistant surface 122 mayinclude, but is not limited to polyethylene, plastic, ceramic material,metals, and magnetic materials. At a minimum, the wear-resistant surface122 has a thickness of 0.1 to 15 mm, preferably 4 to 7 mm, if composedof currently available forms of polyethylene, protruding above theglenoid bony surface and flat outer surface (or annular brim) 121 of theingrowth shell 120. It may have variable thickness along its dimensionto correct version of glenoid. The wear-resistant surface 122 of theglenoid implant 118, which is approximately pear shaped, has both asuperior-inferior dimension and an anterior-posterior dimension. Thesuperior-inferior axis has a suitable range of from about 20 to 60 mm,preferably from about 30 to 48 mm. The anterior-posterior axis definesan upper half and a lower half. The lower half anterior-posterior axishas a range of about 15 to 50 mm, preferably from about 21 to 35 mm. Theupper half has a range of from about 10 to 50, preferably 18 to 33 mm.The ratio of the upper half to the lower half is approximately 0.8 to1.0. The ratio of the lower half of the anterior-posterior axis to thesuperior-inferior axis is approximately 0.7 to 1.0, whereas the ratio ofthe upper half of the anterior-posterior axis to the superior-inferioraxis is approximately 0.6 to 1.0. In addition, the radius of curvatureof the superior-inferior axis of the glenoid surface is greater than thecoronal radius of curvature of the humeral surface of the humeralimplant with which the glenoid implant articulates. Theanterior-posterior radius of curvature of the glenoid surface is largerthan the axial radius of curvature of the humeral surface. It may havevariable thickness along its dimension to correct version of glenoid.

To prepare the humerus for a conventional humeral implant, the humerusis adducted and extended to line up the axis of the intramedullary canalwith the first anterosuperior passage. With the self-retaining rotatoryinterval retractor 5 in place, the humeral canal is prepared usingconventional instruments, trials are used to determine the proper fitand size of the implants, and the proper conventional humeral implantwith an intramedullary stem is either cemented or press-fit into theproximal humerus 20 in accordance with the present.

For the novel humeral implant 94, the humerus does not require specialpositioning. After humeral trialing, the novel humeral stem 98 is placedin the transhumeral portal 30 from either the first or secondanterosuperior passages and the novel modular head 96 is insertedthrough the anterosuperior passage. The two components 96, 98 are thenmated together.

The novel humeral implant 94 in accordance with the present invention ismodular and includes a humeral surface 96 component, a roughlyhemispheric shaped surface with a short central mating device 100, and atranshumeral stem 98 which fills the transhumeral portal 30 (FIGS. 15a-b). Alternatively, a novel humeral surface implant that includes only ahumeral surface 96, with no stem 98 may be used when warranted.Preferably, however, a novel humeral implant 94 with two components 96,98 is used. The two components, the humeral surface 96 and stem 98, areremovably attached to one another. The humeral surface 96 has a coronalradius of curvature and an axial radius of curvature. The humeralsurface can be spherical in shape. Preferably the humeral surface can bemore anatomic being spherical, with equal coronal and axial radii ofcurvature, in the center and elliptical, with larger coronal than axialradii of curvature, at the periphery. A suitable range for the coronalradius of curvature is from 10 to 50 mm, preferably from 19 to 28 mm,with approximately 81% of all men having a coronal radius of curvatureranging from 23-28 mm, and 79% of all women having coronal radius ofcurvature ranging from 19-22 mm. A suitable range for the axial radiusof curvature of the humeral surface of the implant is from 10 to 50 mm,preferably from 18 to 26 mm. The humeral surface 96 of the implant 94also has a depth and thickness. A suitable range for the depth of thehumeral implant 94 is from 5 to 40 mm, preferably from 15 to 24 mm, andthe depth is the same in both the coronal and axial planes. The humeralsurface 96 thickness has a range of from 0.1 to 5 mm, preferably from 1to 3 mm. The ratio of the depth to the coronal radius of curvature isapproximately 0.7 to 0.9. See Table 1.

TABLE 1 Radius of Depth (mm) curvature (mm) 15-17 18-20 21-24 19-20 10 32 21-22 7 18 3 23-24 0 9 18 25-26 0 8 14 27-28 0 0 4 Table 1 showssuitable and preferred ranges of radius of curvature and depth for thehumeral surface of the humeral implant. (See Iannotti J P, Gabriel J P,Schneck S L, et al. The normal glenohumeral relationships: an anatomicalstudy of one hundred and forty shoulders. J Bone Joint Surg 1992;74A(4): 491500.)

The humeral surface 96 of the humeral implant 94 may be sphericallyshaped or more of an elliptical shape which better approximates theanatomy of a natural humeral head. The humeral surface 96 may be made ofa variety of materials including, but not limited to cobalt-chromealloys, ceramic materials, metals, and magnetic materials. It iscontemplated that the humeral surface may also have fins, spikes, orother protuberances on its concave, non-articular surface to enhancerotational stability. Additionally, the concave, non-articular surfacemay also contain a bony ingrowth material. A bony ingrowth materialallows the bone to which the implant is attached to grow into theimplant and aids in attaining long-lasting fixation of the implant.These ingrowth materials, include, but are not limited to autologous andallograft osteoprogenitor cells and tissues, bone-morphogenic proteins,hydroxyapaptite coating, trabecular metal, porous metal, porous metalcoating, and tantalum. It is contemplated that the surface of thehumeral surface component 96 of the implant 94 that articulates with theglenoid or the glenoid implant, is smooth with a low coefficient offriction.

The stem 98 of the modular humeral implant 94 is sized to fit within thetranshumeral portal 30 located along the central axis of the neck of thehumerus. By fitting, it is meant that the stem 98 fits in a tight mannerand is stable in that location. As it is contemplated that thetranshumeral portal 30 has a diameter of from 0.1 to 5 cm, the diameterof the stem 98 is also from 0.1 to 5 cm, and is dimensioned to fitwithin the transhumeral portal 30. The stem 98 may be composed of anysuitable materials including, but not limited to titanium, stainlesssteel, cobalt-chrome alloy. The stem 98 may be smooth, textured, orthreaded. Smooth glass bead blast finishes are another possibility.Threads may be uniform or may vary in width along the length of thestem. Further, the shape of the stem 98 is intended to accommodate theshape of the transhumeral portal 30, therefore it may be round, square,triangular, or any other geometric shape that may comprise thetranshumeral portal 30. The main body of the stem 98 has a consistentcross-sectional shape and size along its straight longitudinal axis.Therefore, unlike conventional humeral implant stems, which are taperedand bowed to fit within the dimensions of the metaphysis and diaphysisof the humerus, the stem 98 of the present invention maintains a uniformdiameter and is linear from end to end. As such, the stem is dimensionedto sit within the epiphyseal and metaphyseal portions of the humerus. Asdescribed for the humeral surface 96, the stem 98 may also contain finsor spikes to aid rotational stability, and it may also possess a bonyingrowth material surface, as describe above.

The stem 98 may be of varying lengths, a suitable range of which is fromabout 4 to 7 cm. The preferred length is dimensioned to extend from thelateral cortex of the humerus to the center of a humeral head. It isintended that this stem 98 be introduced into the transhumeral portal 30via the second anterosuperior incision and advanced through thetranshumeral portal 30 to a position that is suitable for mating withthe humeral surface 96 which is inserted via the anterosuperiorincision, described above. If appropriate, the stem 98 may also beinserted from the articular surface of the proximal humerus through thefirst anterosuperior passage.

The humeral surface 96 and stem 98 of the humeral implant 94 connect toone another via a mating site 100. The humeral surface 96 and stem 98are joined within the glenohumeral joint space. They may be press fit,screwed together, or joined by morse taper, as well as any othersuitable locking mechanism. It is possible for the male or femalecounterpart to be on either the stem 98 or the humeral surface 96, solong as one male counterpart and one female counterpart are present inthe humeral implant 94.

The humeral surface 96 component is inserted through the anterosuperiorpassage and mated with its stem 98 placed through the transhumeralportal 30. The humeral surface 96 and modular stem 98 implant can becemented or press-fit to the prepared humeral surface and there are manypossible variations of the implant 94. Examples A, B, and C are variousembodiments of a humeral implant 94 in accordance with the presentinvention. Example A includes a hemisphere shaped humeral surface 96 anda threaded transhumeral stem 98 (FIG. 16). The humeral surface 96component is inserted through the anterosuperior passage and is eithercemented or press-fit onto the humeral surface 20 and then impacted onthe prepared humeral surface against the glenoid 22. The hemisphereshaped surface 96 is rotationally stabilized with a rod inserted into ahole at a peripheral edge of the hemisphere shaped surface 96 while thethreaded humeral stem 98 is advanced through the protective sleeve 15from the transhumeral portal guide 14 and up the transhumeral portal 30to engage with the non-articular side of the hemisphere shaped humeralsurface 96. The threaded stem 98 has a double pitch with finer pitchedbut deeper cancellous threads that engage and fill the transhumeralportal 30 and slightly wider pitched more shallow threads on thenarrower diameter tip which engages the humeral surface 96 component soas to secure the humeral surface 96 component. Should it be necessary,removal of the example A implant 94 is conducted by recreating bothanterosuperior passages, inserting a driver for the threaded stem 98through the second anterosuperior passage, inserting a stabilizing rodinto a peripheral edge of the humeral surface 96 component from thefirst anterosuperior passage and backing out the stem through theprotective sleeve 15 from the transhumeral portal guide 14. The humeralsurface 96 component is then removed by sawing across the base of thehumeral surface 96 component at the anatomic neck of the humerus with apower or Gigli saw.

Example B includes a similar humeral surface 96 component and a cementedtranshumeral stem 98 (FIGS. 17a-c ). Again, the humeral surfacecomponent 96 is inserted through the anterosuperior passage, is eithercemented or press-fit onto the prepared humeral surface 20 and impactedon the prepared humeral surface 20 against the glenoid 22. Anothertranshumeral stem 98 which possesses the male end of a morse taper isinserted into the female end on the non-articular side of the humeralsurface component 96 and impacted against the glenoid. This stem 98 maybe press-fit or cemented to the bony transhumeral portal. An endcap 106is threaded into the non-articular side of the stem 98 to assist withlater removal of the humeral surface implant 94. To fix with cement, acementation catheter 84 is assembled to an opening in the endcap 106 andcement is injected through the cannulated transhumeral stem 98 exitingholes 99 at its articular end. The cement is injected until it becomesvisible around the non-articular end of the stem 98. Should it benecessary, removal of the example B implant is conducted by recreatingthe anterosuperior passages, removing the endcap with a T-handledwrench, threading the removal shaft 111 into the stem 98, drilling outthe cement-implant interface with a coring reamer 110 over the stem 98,and disimpacting the stem 98 from the humeral surface component 96 witha disimpaction sleeve 112 (FIGS. 18a-b ). The humeral surface component96 is removed by sawing across the base of the humeral surface component96 at the anatomic neck of the humerus with a power or Gigli saw.

Example C includes a similar humeral surface 96 component and aninflatable transhumeral stem 98 (FIGS. 19a-b ) similar to technologyused in the FIXION™ IM Nail (See “A New Expandable Implant for theRepair of Long Bone Fractures”, Sinha, Anjoy M. D. et al, published inwww.Healthfocus.com). Again, the humeral surface component 96 isinserted through the anterosuperior passage and either cemented orpress-fit, and further impacted on the prepared humeral surface 20against the glenoid 22. Another transhumeral stem 98 which possesses themale end of a morse taper is inserted into the female end on thenon-articular side of the humeral surface 96 component and impactedagainst the glenoid 22. The inflatable stem 98 is an expandable tubethat is reinforced with longitudinal bars and has a one-way valve systemon the end that doesn't mate with the humeral surface component. Oncepositioned, the stem 98 is inflated or expanded from its collapsedposition with a specialized saline pump to fill the stem 98, within thetranshumeral portal 30, and gain purchase. The stem 98 can be removed bydeflating it with the same pump and disimpacting the stem 98 from thehumeral surface 96 component with a disimpaction sleeve 112. The humeralsurface component 96 is removed by sawing across the base of the humeralsurface 96 component at the anatomic neck of the humerus with a power orGigli saw.

After the prosthetic implants, either humeral or glenoid, novel orconventional, are inserted as described above, the soft-tissue tensionis evaluated, and the wounds are copiously irrigated, the deep passages,subcutaneous tissue, and skin are closed with sutures.

In yet another embodiment, the present invention is a glenohumeral jointwith a transhumeral portal 30 along the central axis of the neck of thehumerus and at least one implant. The implant may be a humeral implant94, a glenoid implant 118 or both. The implants may be conventionalimplant or novel 94, 118 described herein.

In an alternative embodiment of the present invention, there is provideda method of repairing a rotator cuff, tear as shown in FIGS. 28-33. Thisprocedure may be utilized in conjunction with the above described methodof shoulder replacement or it may be used as a stand-alone procedure. Inthis method standard positioning and techniques for arthroscopic or openrotator cuff exposure are employed. If performed in conjunction with thepreviously described methods of shoulder replacement surgery, theanterosuperior passages may be used. If performed in isolation, an opendeltoid split or arthroscopic subacromial exposure used for rotator cuffrepair is performed in standard fashion. A small longitudinal stab ismade through the skin and superficial deltoid fascia approximately 5-12cm below the level of the anterolateral edge of the acromion.

In one embodiment of the rotator cuff repair method, an insertionalguide 134 is inserted with a protective inner sheath 137 (FIGS. 28a-b ).The insertional guide 134 includes a cannulated handle 134A and acannulated tip 148. The cannulated tip 148 is an elongated rigid tubewith a sharp trocar tip 150. The diameter of the rigid tube and trocartip 150 is slightly larger than that of the leading flexible pin 140 ofsuture pin device 141 adjacent its sharp leading end 154 (FIG. 29)described below, and is approximately 1.0 to 5.0 mm An inner protectivesheath 137 may be used with the insertional guide 134 (FIG. 28b ). Theinner protective sheath 137 screws into the handle 134A of theinsertional guide 134. The inner protective sheath 137 has a handle 138that acts as a stop and prevents the inner protective sheath 137 fromextending further into the insertional guide 134 than the level of theprotective sheath handle 138. The inner sheath 137 has a blunt end 139that extends beyond the level of the sharp trocar 150 of the insertionalguide 134, providing a non-sharp surface with which to enter the tissue.When the surgeon is prepared to use the sharp trocar tip 150 ofinsertional guide 134, the inner protective sheath 137 is removed byunscrewing the handle 138 and sliding it out of the insertional guide134. Optionally, an outer protective sheath may be used that extendsover the tip of the insertional guide 134 and provides a blunt end aswell. In this embodiment, the outer protective sheath has a longitudinalsplit so that it may be peeled off of the insertional guide when thesurgeon is ready to use the sharp trocar tip 150 of the insertionalguide 134. The bore tip 150 is extended into the lateral humeral 20cortex under direct or arthroscopic visualization (FIG. 30). Anarthroscopic retractor 136 may assist the process. Directed by aninsertional guide 134 a flexible pin 140 is advanced by a drill throughthe greater tuberosity of the proximal humerus to exit into ananteromedial supraspinatus rotator cuff footprint. The next step is toreduce the torn edge of the supraspinatus tendon with a soft tissuegrasper 138A. The flexible pin 140 is advanced through the cuff (FIG.31) and out through the superior soft-tissue and skin using a pindirector 142 as needed (FIG. 32). The suture-pin devices 141 may passthrough the acromion or deltoid as necessary. These steps, namely,advancing the suture pin through the greater tuberosity of the humerus,the supraspinatus rotator cuff tendon and out of the shoulder throughthe superior soft tissue and skin, are done, as described, in a singleunidirectional pass. The drill is switched to a suture pin leading tipand the flexible pin component 140 is removed from the body. Theflexible pin 140 is cut from the suture 144. The above steps may berepeated as often as necessary to provide sufficient sutures 144 tosecure the torn rotator cuff. For the arthroscopic technique, a tyingcannula 146 is then inserted for tensioning and securing suture 144outside of the humerus inside the shoulder (FIG. 33). The sutures 144are retrieved and passed in modified Mason-Allen fashion if desired,using free needles (open technique) or an arthroscopic suture passingdevice. The sutures 144 are tied and the tying steps are repeated. Therepair may be reinforced with lateral suture anchors as needed before orafter tying the transosseous sutures 144 (FIG. 33).

The suture-pin device 141 comprises two components, a leading flexiblepin 140 and a swedged on suture 144. The suture 144 is preferably adurable size #2 suture 144. The pin 140 has a sharp slightly largerdiameter trocar tip 154 on its leading end. The remaining pin 140 has adiameter closer to that of the suture 144. The pin 140 is sufficientlylong to enter the anterolateral surface of the shoulder, pass throughthe proximal humerus, rotator cuff, and exit the superior surface of theshoulder with both its leading and trailing ends are exposed. The suture144 is of similar length.

It is therefore intended that the foregoing detailed description beregarded as illustrative rather than limiting, and that it be understoodthat it is the following claims, including all equivalents, that areintended to define the spirit and scope of this invention.

I claim:
 1. A glenoid implant comprising a shell having a protrudingsurface on a first side arranged to engage the surface of a cavityformed in a glenoid extending between peripheral glenoid surfaces, and aflat surface on the first side adjacent the protruding surface arrangedto engage the peripheral glenoid surfaces adjacent the cavity, and awear-resistant articulating surface on a second side opposite the flatsurface and the protruding surface.
 2. The implant of claim 1 whereinsaid shell includes a cannulation.
 3. The implant of claim 2 whichincludes a first cannulation arranged to accept a screw compressing thewear-resistant surface into the cavity.
 4. The implant of claim 3 whichincludes cannulations arranged to angularly dispose screws into theglenoid.
 5. The implant of claim 4 in which the angularly disposedscrews are directed into engagement in a peripheral cortex of theglenoid.
 6. The implant of claim 5 in which at least some of theangularly disposed screws are held in locking engagement with the shelland in a fixed depth and direction in the glenoid.
 7. The implant ofclaim 1 wherein said shell includes an ingrowth material to promote bonegrowth and adhesion of said shell to a glenoid surface.
 8. The implantof claim 1 wherein the wear-resistant surface has a thickness dimension.9. The implant of claim 8 wherein the wear-resistant surface is adaptedto extend into the cavity.
 10. The implant of claim 1 wherein thewear-resistant surface has a first thickness dimension adjacent oneperipheral glenoid surface greater than a second thickness dimension ofthe wear-resistant surface adjacent a peripheral glenoid surface spacedapart from the first thickness dimension.
 11. A glenoid implantcomprising a protruding surface on a first side arranged to engage thesurface of a cavity formed in a glenoid extending between peripheralglenoid surfaces, and a substantially planar wear-resistant articulatingsurface on a second side opposite the protruding surface.